Assume all the same figures in our traditional plan assumption, except that any manufacturer payment does not count toward the beneficiary’s deductible, coinsurance, or out-of-pocket maximum. Now consider a very simplistic scenario involving a plan design with a co-pay accumulator component (Table 2). These numbers are fabricated, and for the sake of simplicity, they ignore any other outside factors that could affect a beneficiary’s deductible and/or out-of-pocket maximum. Once the beneficiary’s out-of-pocket maximum is reached, the plan sponsor absorbs 100% of any further cost of the medication for the rest of the benefit year.įor example (Table 1), take a very simplistic (and likely unrealistic) traditional plan design, with monthly drug spend on a fictional single specialty medication spread over a 12-month benefit year among plan sponsor, manufacturer, and patient. This assistance has normally been in the form of a co-pay coupon or a co-pay card. Traditional plan designs have allowed for manufacturer assistance to count toward a beneficiary’s deductible and overall out-of-pocket maximum. How They Work and the Advantage for Plan Sponsors One of the most discussed and debated topics in 2018, these programs are an issue that various stakeholders grapple with on a daily basis and a challenge that will likely persist in the coming years.Īlso called coupon adjustment, out-of-pocket protection, accumulator adjustment, and variable co-pay, the programs function in the same capacity regardless of their name and seek to dull the adverse financial impact on payers of manufacturer co-pay assistance. Has witnessed their relatively rapid and widespread adoption over the past few years.
These plans are commonly known as co-pay accumulator programs or co-pay accumulator adjustment programs, depending on the PBM and the plan sponsor, and the industry
Pharmacy benefit managers (PBMs) have begun offering plan sponsors a new prescription drug benefit plan design that revises the historical treatment of manufacturer payments for costly specialty medications. With ongoing growth across the board, plan sponsors are continuously searching for ways to minimize the impact on their bottom line. The drugs that treat high-touch, costly conditions often have a monthly price tag of a few hundred to tens of thousands of dollars and their spend continues to grow, the result of both an increase in drug cost and specialty therapy utilization. Specialty medications treat a wide range of conditions, from Crohn disease to cancer, and new specialty products are introduced every year.
0 kommentar(er)
